PAC — The Anaesthesiologist's OPD

The first time I sat down in the PAC clinic, I didn't know what to expect.

A small room. One desk. Two chairs. No monitors beeping, no laryngoscope within reach, no trolley stocked with emergency drugs. Just a man sitting across from me — not in distress, not in urgency — simply waiting. Watching. Wondering, perhaps, what the anaesthesiologist wanted with him before his surgery.

He was 45. Male. Healthy-looking. Posted for laparoscopic cholecystectomy.

And in that quiet moment, before either of us had spoken, I understood something: this conversation — unhurried, unmonitored, without the soundtrack of an emergency — carried more weight than I had anticipated. What we discussed here would determine everything that happened to him once those OT doors closed behind us.

Five questions we always ask ourselves

For every procedure · Every drug · Every decision

For every procedure, every drug, every clinical decision we make as anaesthesiologists — we anchor ourselves to the same five questions. The PAC is no different.

The purpose of the PAC

Not paperwork · Not formality · Our domain

The PAC — Pre-Anaesthetic Check-up — is the formal consultation that takes place before any surgical procedure. It is where the anaesthesiologist meets the patient, reviews their clinical status, and begins building the anaesthetic plan.

But that is the textbook answer. The lived answer is something different. The PAC is where the anaesthesiologist becomes a physician first — before she is a technician, before she is a proceduralist, before she is the person in charge of airway and haemodynamics inside an OT. It is the only moment in the surgical journey where the patient and anaesthesiologist exist outside the urgency of the operation.

Timing — and why it matters

Before the list · Outside the rush

The ideal PAC takes place at least 24–48 hours before surgery. Not minutes before wheeling the patient in. Not the morning of, while theatre is being prepared. Before. Because the PAC exists to give you time — time to investigate, time to optimise, time to change the plan if the plan needs changing.

At NIMS, the PAC clinic sits in the surgical OPD complex. One room. One consultant or resident. One patient at a time. And from that room, decisions flow outward — to the surgical team, to the investigation desk, to the ward — determining who goes in on that list, and in what condition.

Listening before we look

I introduced myself first. I told him I would review him before his surgery — that we would take it step by step, that he had nothing to worry about yet. I watched something shift in his posture. Not relief. The beginning of it.

Then I asked: What brings you here today?

He told me about a pain on the right side of his abdomen — two months of it, visits to multiple OPDs, medications tried and discontinued. He wasn't in acute distress right now, but the discomfort had settled into his daily life. On further questioning: altered bowel habits, early satiety. Pain was his primary complaint.

The clinical mind was already working. But I let him finish. Because in the PAC, the history is not merely about the presenting complaint — it is about everything that might touch the anaesthetic.

His answers: no comorbidities, no regular medications, no prior surgeries, no known allergies. A clean slate — the kind that makes you quietly grateful, and quietly careful not to miss something beneath it.

Then I asked him to show me the surgeon's notes. And there it was: chronic cholelithiasis, posted for laparoscopic cholecystectomy. The complaints had mapped exactly where the clinical mind had expected them to. I felt the quiet satisfaction of a story that makes sense — and reminded myself that this satisfaction is also where complacency begins.

What the body tells us that the patient cannot

With his consent, we moved to the examination. General appearance, vitals, systemic examination from head to toe — each system yielding its findings in the language of physiology rather than complaint.

And two measurements that are quietly essential and quietly forgotten: height and weight. Not incidental. Not afterthought. From these numbers flow drug dosing, airway prediction, and risk stratification. Ignore them and you are working in the dark — confident and wrong.

Then came the part that belongs entirely to us.

Our examination — and no one else's

I told him I needed to examine his airway — and I explained it in words he could understand, not in anatomy. He nodded. He leaned forward slightly, cooperative now in a way he hadn't been at the start of the consultation.

The airway examination is where the anaesthesiologist is most entirely herself. No other specialty performs this. No other specialty needs to. This is our domain — and we must own it with the precision it demands.

Then the spine. I asked him to lift his shirt, and I looked — not cursorily, but with intention. Any visible deformity or scoliosis. Prior surgical scars. Skin changes or infection over the lumbar region. Each finding reshapes the regional anaesthesia plan before the drug has even been drawn up.

I palpated the interspinous spaces — and explained the position we would need him to assume if a spinal block was planned. He listened. He asked a question. And in the act of answering it, I realised something that no textbook had told me explicitly: this explanation was not just education. It was preparation. A patient who knows what to expect cooperates better, positions better, tolerates the procedure better. The pre-operative conversation is already a clinical intervention.

Evidence to support the decision

The fifth pillar of the PAC: laboratory investigations. Not ordered reflexively, not as a defensive shield — but chosen deliberately, in response to the history and examination, to confirm or challenge what the clinical picture suggests.

His findings were unremarkable — as we had expected. But the act of reviewing them carefully, correlating them with what we had found clinically, completed the picture. Nothing was assumed. Everything was confirmed.

He left the clinic less worried than he had entered it. I don't know if he noticed the shift in himself. I noticed it in him — the way his shoulders had settled, the way the last question he asked was curious rather than afraid.

That is what the PAC does. And what no one tells you until you sit across from a patient in a quiet room, with no monitors and no emergency, and only a conversation between you and the decisions that will follow.

The OPD was always what we dreamed of. In anaesthesiology — this is ours.